Sam Berman Dr. Kim Ferguson Samantha Dalby NP

Sam Berman Dr. Kim Ferguson Samantha Dalby NP

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CE LHIN Total population = 1,463,801

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Estimated Family Physician shortage of 55 – 110

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Unattached patient estimate of 86,000

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Purpose was to provide unattached residents in the CE LHIN access to a full general assessment, screening, diagnosis of disease, referral to specialists and programs as needed and education The model reviewed by CPSO, CMPA, RNAO, and CNPS

Equal access to assessment and screening Early detection of asymptomatic disease Management of illness/disease Modification of health risk factors Reduced acuity and ED visits

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Earlier detection and management of disease reduces overall health care costs Program provided a way of addressing shortage of primary health care providers (HCP) in the CE LHIN Program increases the likelihood of take-up by existing primary HCPs

Self Refer or HCC Refers Unattached Patient to UPA Patient attends Intake Visit with RN for Medical History and Screening Tests Arranged Patient attends Assessment visit with NP/MD 1. Review of patient profile 2. Physical exam performed 3. Screening results reviewed Results NORMAL

Patient given results and education for FU

Results ABNORMAL & STABLE

Results ABNORMAL & UNSTABLE

Patient given results, referrals for Chronic Disease Management and education on ongoing care & FU

Patient to ER then back for results Mngt, Referrals and education on ongoing care & FU

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Physicians billing Fee For Service for most activity Remainder of UPA required funding for NP consults, NP salaries, RNs, clerical staff equipment and operating costs

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Average cost of $200 per patient

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First 600 rural patients that completed screening Number of patients with >=1 new diagnoses was 255 New Diagnoses: CVD 64 HTN 11 Dyslipidemia 119 DM 18 IFG/IGT 51 Metabolic Syn 53 COPD 41 CRF 6

Cancer Psychiatric GI Uro/Gyne MSK Rheumatologic Osteoporosis

11 16 5 28 34 3 16

According to the Cost of Chronic Disease in Canada “preventative interventions should be

justified on the same grounds as acute care interventions...on the grounds of cost

effectiveness”

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Contacted MOH, PHL, ICES, OCCI, CIHI for data Unable to determine the burden of illness in each disease category Used Canadian Institute for Health Information’s (CIHI) Patient Cost Estimator to determine the cost of each hospitalization using Case Mix Groups(CMG) The lowest cost estimate was chosen for each disease category and only includes hospital cost Underestimated that only 1 hospitalization will occur for each disease category NO physician billing, allied health, indirect costs or quality of life burden were taken into account

CVD 64 HTN 11 Dyslipidemia 119 DM 18 IFG/IGT 51 Metabolic Syn . 53 CRF 6 COPD 41 Cancer 11 Psychiatric 16 GI 5 Uro/Gyne 28 MSK 34 Rheumatologic 3 Osteoporosis 16

CABG MI PCI (no MI) Foot Amputation CVA PVD Kidney Disease Respiratory Failure Breast Lumpectomy Mood Disorder IBD Total Hysterectomy Knee Replacement Arthritis Hip Replacement

TOTAL

$32,452 7,728 10,981 10,158 7,153 6,437 8,521 21,922 4,365 6,681 5,052 4,831 9,295 5,634 10,186

$ 151,396

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There were over 1.7 million people in Canada with DM in 2009 which represents >5% of population (similar to our sample) ~4 million patients in Canada are without a primary care provider This estimates ~200,000 people with DM that are unattached from primary care In 2010 just the direct cost of hospitalization of patients with DM was $4.9 billion Imagine the cost for the remainder of undiagnosed disease in the unattached patient ???

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There is a high incidence of asymptomatic disease and risk in the unattached population Lack of access is creating high numbers of premature pathology, morbidity and mortality A patient’s right to access a general assessment and preventative health care screening may be a federal and provincial legal right rather than a health care goal The cost of lack of access is undoubtedly costing billions in direct health care costs alone

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Full Integration with HCC to provide general assessments to those patients NOT picked up within 2-3months of HCC registration Use Retired Docs, supervised Medical Residents and Nurse Practitioners Implement programs within FHTs, CHCs and NP clinics to utilize existing infrastructure